Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 313

Safe, high‐quality care for older people requires staff to make complex decisions about medical and non‐medical matters, with the involvement of the whole multidisciplinary team and with the aim of meeting patients’ best interests. This applies across the entire healthcare system, including decisions relating to the prevention and management of long‐term conditions in primary care, when and whether to refer or admit patients to secondary care, inpatient care, and the complex planning required to maximize patient safety on discharge from the hospital. The challenge is to make these decisions in the safest possible way by anticipating and pre‐empting potential errors or harm and always acting in the patient’s best interests.

Very old people, particularly those who are frail and complex, have in the past often been excluded from the large clinical and pharmaceutical trials⁴⁶ that have formed the basis of our pharmaceutical approach to treating many common conditions. To a certain extent, this is understandable: the different physiological characteristics, coexisting medical conditions, and therapies associated with old age can lead to a variety of responses to drug therapy, both beneficial and adverse; these responses can be difficult to predict, detect, and adjust for accurately in terms of measured outcomes. As a consequence, optimal therapeutic decision‐making for the individual – for instance, in terms of drug dosing or combinations – may be difficult to achieve because of the lack of an appropriate evidence base. Hence a degree of clinical judgement based on the risks and benefits of treatment in the context of elderly, frail physiology needs to be used to make such decisions. In recent years, it has become more apparent that older people are the target group for many treatments, and trials have increasingly been designed with these patients in mind.⁴⁷

Commonly used therapeutic guidelines can also be difficult to generalize to older people; particularly when used by those who are not au fait with geriatric medicine (such as relatively inexperienced prescribers or prescribers in settings that are more used to dealing with younger or fitter people), this can result in inappropriate treatments being given to frail older people, with adverse consequences that may include over‐ or under‐treatment, for example with opiate analgesia. Even in conditions where a strong consensus and clear guidelines for management exist, there is evidence that treatment remains inadequate. This is particularly true of conditions such as delirium, where appropriate management requires a concerted team effort and a multifaceted approach. There is evidence that such guidelines are not always followed: this demonstrates that if they are to be implemented universally and successfully, concomitant educational and organizational changes are necessary.⁴⁸

As the needs of each person within this population are so heterogeneous, care must be taken to tailor decision‐making to the individual. Training to develop these difficult decision‐making skills is also often lacking, and this ability is usually expected to develop with experience. Cognitive biases and failed heuristics²³ are more likely to occur when the information presented to the decision‐maker is complex and of varying quality, as is often the case in the care of these patients. Another problem is that whereas younger people might expect and be able to take part in the clinical decision‐making process, older people often prefer not to be involved to the same extent⁴⁹ or are not able to do so. When making complex decisions such as care planning near the end of life, multiple factors need to be taken into consideration, such as the health status of the patient and their values and individual goals, so that the best interests of the individual are met. All of these factors make decision‐making difficult with the frail elderly, and any failure in this process can lead to undesirable consequences.